Healthcare Provider Details

I. General information

NPI: 1891829560
Provider Name (Legal Business Name): KIMBERLY LYNN UNDERWOOD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1934 NILES CORTLAND RD NE STE B
WARREN OH
44484-1055
US

IV. Provider business mailing address

1934 NILES CORTLAND RD NE STE B
WARREN OH
44484-1055
US

V. Phone/Fax

Practice location:
  • Phone: 330-841-4032
  • Fax: 330-841-4381
Mailing address:
  • Phone: 330-841-4032
  • Fax: 330-841-4381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.002206
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: